14 September 1998

1. Caring for A Child in His Parents' Absence
2. Colic and Diarrhea, or Worried Parents
3. Constipated Infant
4. Still Drooling
5. Hiatus Hernia and Ulcer
6. Child Refuses to Have BM in Toilet
7. Abdominal Pains
8. Food Allergy
9. Disclaimer

• Read Questions & Answers in Another Column

Caring for a Child in His Parents' Absence

I have a two-year old, but have no idea how to handle a 7-year old, much less one who will be going through a traumatic separation. He's a very intelligent child and my husband and I get along well with him. He's happy and pretty well adjusted for being an only child with a single mother. However, he is having a few problems in school right now such as talking too much, even when the teacher is talking. He recently got in trouble for spitting at the janitor (the teacher believes he was showing off).

I have two questions:

1. How do I address the issues my nephew will be facing, i.e. the separation and possible problems at school? (I liked your idea of a chart with levels of behavior!)
2. How do I handle the jealousy I'm almost positive my son will be feeling?

-KW

Dear KW: Some of the difficulties your nephew will be facing will depend on his prior experience with separation from his mother, how well prepared in advance he is for the separation, and what opportunities there will be for him to visit or communicate with his mother during her absence. He may need significant and repeated reassurance that his mother loves him. He may need to do things regularly to plan for his mother's return to keep the reality of that return fresh in his mind, for example, he might keep a journal or a photo album of his life with you in which he makes regular entries to share with his mother when she returns. Regular communication with his mother will help your nephew to deal with the separation. The more consistent and dependable the communication is the better. If your nephew can expect to hear from his mother at specific times at regular intervals, he can develop a routine or ritual surrounding the communication that enhances the experience and gives him something to look forward to and plan for. One caution is that such a dependable communication ritual can lead to severe disappointment if an expected appointment is missed, therefore, every effort must be made to avoid the unexpected. Extra communication with Mom may be a nice surprise, but your nephew also has to know in advance when he can expect to hear from her again.

The most important thing you can do for your nephew besides keeping his relationship with his mother an active (current) source of strength, support, and love for him, is to provide him with as normal a life as possible. Give him your love and provide him with opportunities for fun that all children should have, but even though you may be understanding about the manner in which your nephew's separation from his mother affects him, don't overcompensate for it. Your nephew will find security in knowing that you are in charge and that he has rules which will be enforced consistently no matter how compassionately. If you spend the early weeks of your nephew's separation from his mother trying to drown his sorrow in fun, presents, and treating him like a little king, you will not win his love or cooperation, and you will give him unreasonable expectations about what his life with you will be like for the next year. You should be flexible and understanding in teaching your nephew your rules, recognizing that he has an adjustment to make and may have new rules to learn. Your process of discipline should be a learning experience with gentle but consistent enforcement. But don't make his adjustment period a grace period without rules or you will create a monster that you won't be able to live with and you may spend the remainder of the year fighting to regain control. This will not result in an atmosphere where he feels loved. Never lose sight of the fact that controlling your nephews behavior keeps him safe, provides him security, and is an act of love.

If your nephew is very troubled by his mother's departure or the prolonged separation, help him to find acceptable ways of expressing his feelings. Keep in mind that all feelings are legitimate. He should not be expected to suppress or deny feelings of anger or sadness. In fact he should be permitted and even encouraged to express his feelings, but he must learn that his bad feelings will not excuse unacceptable behavior or modify his rules. If you read my articles on behavior you should remember that I suggest not burdening a child with so many rules that he can't please you. Keep the rules basic and simple and make adjustments in your house and your life so that your nephew can learn your values rather than a million "don'ts."

Your son will no doubt need some time to adjust to your nephew. This adjustment will be affected by what ever prior relationship your son and nephew had. Every effort should be made to make them friends and allies rather than competitors for your attention. To accomplish this, try to provide both of them with special time for each of them individually where each at his time is the center of your attention. Do this at regular and dependable intervals so that the children learn their routine. For the remainder, and bulk of the time, try to involve them in each others lives. Let your nephew feel like a big boy by helping you take care of your baby. Try to provide your baby with activities that parallel his big cousin's, for example, have him sit with you with crayons and paper so he can "write" just like his cousin when you are helping your nephew with homework.

In addition, make time for your son by getting your nephew involved in activities and your neighborhood. It's important for your home to become the center of your nephew's life for the next year, but at 7 years of age, he also needs friends and activities appropriate for his age. If he will be attending a new school and is far from his old neighborhood, you will have to make an extra effort to help him get involved at the midyear point. Make sure you are familiar with your nephew's interests and his current activity schedule and see if you can get him involved in activities in your neighborhood before he moves in with you. This also provides an opportunity for his mother to help him make the transition.

Sincerely,
Dr. Warren

He was pronounced healthy by a hospital MD and once home appeared very restless and fussy for the first night. The next day (4 days old) we took him to a friend's ped and after a 3 minute "look see", he was again pronounced healthy. That night he was the opposite of the day prior. The next day and night, he was fussy, restless, seemed to have quite a bit of gas. He would straighten his body in a very tense fashion, clench his fists and cry. This pattern continued until Monday when my wife called the ped and he replied "it appears that our baby may be a bit colicky". He suggested changing the formula from Enfamil with iron Isomil (soy based product). He was 10 days old and we changed the formula to Isomil. He did appear a bit more relaxed initially. However, since said change, he has developed diarrhea and it has continued through today. My wife called the ped and he suggested 2 oz of Pedialyte and 2 oz of Isomil when he is fed for 24 hours.

My concern is that the formula was changed too quickly. We may have been to quick to call him and perhaps should have waited a couple of more days. Babies do cry, right! I am not very excited with any data I obtain on any of the commercial formulas available and even less so with the soy based products. He informs us that the diarrhea may continue for another week or longer - it is tough to predict.

While taking his temp this evening a bowel movement occurred and the beginning was of it was clear until eventually turning a brown-yellow color.

Birth mother had numerous other children (all healthy) with no allergies whatsoever to milk or any other substances. She did have a very low and unexplained iron count during the pregnancy and did not receive prenatal care until the 28th week.

Is the above scenario common???? Any comments would be greatly appreciated!

PS: Are there any alternatives to the commercial formulas available (Enfamil, Carnation and Similac products seen on grocers shelves)?

-D

Dear D: Normal newborn stools are loose with a water margin and may be confused with diarrhea. Healthy newborns may have a bowel movement with each feeding averaging 4 to 6 dirty diapers per day. If the baby is having many more stools than that per day or if the stools are large and very watery, the baby may indeed have diarrhea.

I am not sure what your concerns are about commercial formulas. Don't make the mistake of thinking when you read labels that everything with a long and unpronounceable name is a potentially harmful artificial ingredient. All the B vitamins have foreboding sounding chemical names. Soy is a reasonable alternative for infants who don't tolerate milk based formulas, but soy may also cause allergies and some infants don't tolerate soy. An infant who is truly having a problem with formula may do best on a hypoallergenic formula like Alimentum or Nutramigen.

Babies do cry and have gas pains. Since it is a normal part of being an infant, deciding whether or not there is a problem often depends on just how much crying and gas pains you're dealing with. It may not have been necessary to switch formula so quickly, but neither should it have done any harm.

If your infant continues to be extremely irritable and have diarrhea, you might want him to be checked again by the pediatrician just to be sure he is not dehydrated. Your pediatrician should be able to tell you by observing the baby's stool whether or not the stool is normal or really diarrhea. That may put your mind at ease or determine if the baby needs additional intervention or follow up.

Sincerely,
Dr. Warren

-TBB

Dear TBB: You may try giving your baby a little extra water to see if it will help her constipation. Try adding 1 to 2 ounces of water to one or two bottles a day. If that doesn't help, you might consider giving the baby two to four ounces of prune juice per day or adding Malt Supex to the baby's formula. Sometimes a formula change may help. Enfamil, which has more whey (a milk protein) sometimes results in a softer stool.

Sincerely,
Dr. Warren

-PJ

Dear PJ: Some degree of drooling may be normal in a 2-3/4 year old child, especially if he keeps his hands or anything else in his mouth. If he seems to drool even when he has nothing in his mouth he may deserve some evaluation. Certain neurological conditions may be associated with drooling, but if there is no other evidence of developmental delay, the place to start for evaluation would be to see a speech pathologist. The speech pathologist's evaluation of your son's mouth and swallowing could help to determine if there is need for evaluation by any other specialist as well as providing you with a treatment plan aimed at decreasing the drooling.

Sincerely,
Dr. Warren

Here's my problem. I'm 17, female. I have had stomach problems since age 5. About 2 years ago, a gastrorologist (sp?) found that I had a hiatus hernia and duodenal ulcer.

Lately, I have been having discomfort in my stomach and chest area. Sometimes, it gets quite painful. There are differences in how it feels - sometimes I describe it as "tubes being tied into knots", other times, "an animal with claws scratching my insides". I have also been going to the bathroom more than usual, due to loose stools. I feel nauseous at times, and get a burning pain going down my chest. I am wondering if this could be caused by either the ulcer or hernia, and what can be done about it. I have had these problems before, but they seem more persistent this time around.

I was also wondering what your thoughts on surgery on a hiatus hernia. My godmother had it done, and says it worked wonders. My doctor first claimed I wasn't in enough pain, then said I was in more than I should be. He then said the pain was "in my head". I saw the surgeon who did my godmother's surgery, and was told if my doctor agreed, he would do the surgery. He said that he thought it would help considerably.

Any thoughts?

Thank you for your time!

-KM

Dear KM: As a physician who hasn't examined you or reviewed your laboratory data, it's impossible for me to advise you regarding the best management for your specific case. Your symptoms could certainly be explained by both a hiatus hernia or an ulcer. The hiatus hernia could be aggravating the ulcer. If these diagnoses have been made through appropriate evaluation, I'm not sure why your physician would think you're not in enough pain for treatment or it's in your head. If you have an ulcer you should be on an acid blocker such as Zantac, Tagamet, Axid, or Prilosec. If healing can't be demonstrated after an adequate course of therapy, you should have endoscopy to determine what the problem is.

If you have a definite hiatus hernia, you should consult the surgeon who should review your x-ray and other studies to advise you whether or not surgery would be an appropriate option. If the diagnosis is in question, then additional studies would be warranted. If there is no question about the diagnosis, your own opinion regarding how much pain you are in should be the determinant of whether you seek a surgical consultation. If you definitely have an ulcer, to avoid unnecessary surgery, you may need to be sure you have had an adequate course of medical therapy to heal the ulcer before concluding your symptoms are from the hiatus hernia.

It certainly sounds like you deserve some form of treatment aimed at providing you relief from your symptoms and resolution of your problem.

Sincerely,
Dr. Warren

-JAD

Dear JAD: Reasoning with a 3 year old is like talking to a wall. We have to explain our reasons to young children, but they don't speak logic, so we can't expect our explanations to convince them to cooperate. Your daughter would probably like nothing more than to please you, but from her point of view, you're asking the impossible. In order to get her to use the toilet for bowel movements, you need to make sure her stool is soft and easy for her to expel, and you have to get her cooperation in sitting on the bowl after each meal to attempt a BM, but avoid pressuring her. Read my article Potty Training. If you don't find it adequately helpful you might also like to read my article on Fecal Soiling to review the management of stool withholding.

Sincerely,
Dr. Warren

He has had problems with eating and 'pooping' since he was an infant. He used to always cry and the doctor described it as 'colicky'. It is an intermittent problem, but he goes through hell when it does happen.

I have always thought it was something like a twisted intestine, but the doctor says no.

Any help would be appreciated.

-Ian

Dear Ian: A twisted intestine would cause excruciating pain and vomiting. Even though a volvulus (the term for twisted intestine) may sometimes untwist and be intermittent, I would consider it most unlikely that your son could live with it for 2-1/2 years. You did not clarify what problem your son has with having bowel movements, but if he is constipated, that will cause gas pains, bloating, and loss of appetite. If he is a stool withholder (someone who holds in the stool and refuses to have a BM) it will aggravate the problem. The association with cereal could be related to a food sensitivity. If it is the cereal one has to think of wheat sensitivity or gluten sensitivity. If he eats cereal with milk, you have to think of lactose intolerance. You should explore the appropriate diet for your son to deal with either of those sensitivities to see if that is the cause of the problem. At the same time, if he is constipated, you need to review the management of constipation with your pediatrician.

Sincerely,
Dr. Warren

-ETM

Dear ETM: Milk sensitivity does not necessarily imply that your child is highly allergic. To the best of my knowledge, GER has no bearing on the issue. If you have a strong family history of allergy, then additional caution may be in order.

Nuts may be potent allergens, but because they also pose a choking hazard they are rarely an appropriate food to give before 2 years of age. Since peanut butter is sticky, the same rule applies.

Strawberries would be okay to introduce now. A severe allergic reaction could result in hives, wheezing, and in the case of food allergies, vomiting.

Sincerely,
Dr. Warren

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